Computerized records often leave out critical patient information

Protect yourself from the risks of electronic medical records

 

 
October 1, 2015

You may have noticed over the past few years that more and more doctors and hospitals are using electronic medical records, rather than the older style of mostly handwritten records.

The reason that this has happened in such a rush if the 2009 passage of the American Recovery and Reinvestment Act, which created funding, incentives and penalties to get hospitals and doctors to adopt and meaningfully use electronic medical records by 2014. 

As a medical malpractice attorney, I review medical records every day. While electronic medical records are certainly easier to read, I have noticed some problems with them that I believe can endanger patient safety.

First, bigger is not always better. If you print out a set of electronic medical records and compare them to handwritten medical records of a similar patient stay, the electronic set will be two or three times larger. This is because electronic records have numerous fields that get automatically repeated and repeated every shift or office visit.

This alone is dangerous. Of course, it means that useful information is buried in mounds of blather, making it hard to find. 

Further, computerized systems are set up to repeat and re-document previous information into the medical record. Oftentimes, the only way old information gets updated, and not reinserted into the next note, is if the doctor, nurse or tech goes in and manually changes it.

I recently deposed a Houston OB/GYN in case where one of his patients died during a hysterectomy, as a result of a drug interaction. I represent the husband and sons of this lady who needlessly died in her 40s because the doctor prescribed, and the pharmacy filled prescriptions for two drugs that should never be given together.

During that deposition of the OB/GYN, I went through every entry in his office’s electronic medical record for this lady. On two key visits, the “medication list” section was wrong. Clearly wrong. And I asked why. His answer was simply that the computer inserted that information from the patient’s previous visit and no one manually corrected it. The doctor did not really seem distraught by this and even commented that it happens frequently.

That really scares me. So one danger of electronic medical records is that old information may get auto-populated into new medical record entries, making it appear that it was still current.

A second issue is the quality of the information being placed in the electronic medical records in the first place.

Think back to when you were in school and the difference between essay and multiple choice tests. In an essay answer, you had to know your stuff and get to the point. In a multiple choice exam, not so much. 

Electronic medical record systems are designed to present healthcare providers with multiple choice “drop down” menus, where they select, click and move on.

Several doctors and nurses whom I have deposed in medical malpractice suits have testified that these electronic systems multiple choices do not always give the “correct” answer for a symptom or diagnosis. This forces them to select the “best” (but still wrong) answer among the choices that the computer provides.
 
While the computerized systems give healthcare providers the opportunity to make short narrative notes, many of them think that the computerized systems make it difficult or time-consuming to do so. That means they often do not make narrative notes at all.

In my view, electronic medical records have created a system where some doctors and nurses work for the computer, rather than the patient sitting in front of them.

And by focusing on the electronic system, often to the detriment of the patients, important things get left out of the medical record. No doubt, on every shift or office visit, the computer’s boxes are checked and multiple choices made, but oftentimes important clinical information, like changes in the patient’s neurologic status, are completely left out of the records.

This is exactly what happened in another one of my cases. In that case, an elderly lady was in the hospital following a successful surgery to address some neck pain. The surgeon overprescribed a strong narcotic pain killer. The hospitalist continued the prescription, at a reduced but still overprescribed dosage. 

Meanwhile, the patient’s family, who was with their loved one around the clock, started to notice that she was acting differently. She was agitated. She was combative. She was not acting like herself. 

This lady was showing signs of neurologic changes, which are well-known to be one of the earliest signs that something is wrong.
 
The family told the nurses on several occasions. They asked for a doctor to come in. For a period of time, the patient was flailing in the bed so much that the lines were coming loose and the family had to hold her down physically. The family told the nurses again and asked for the help of a doctor.

Believe it or not, none of this terrifying ordeal was documented in the electronic medical records. But the nurses made sure to check all the boxes and make all the selections in the pull-down menus, and it left an entirely different, deceptive record, of what had happened and why this poor lady ultimately passed away.

Fortunately, though, family members were with this lady around the clock. And at the beginning of the hospitalization, her husband and adult children decided to take shifts to stay with her and keep a diary or journal so everyone would know what had been going on with her care.

Needless to say, the family’s journal was much more detailed than the hospital’s medical records. In fact, in the case, it was of tremendous benefit because it allowed us to identify what really happened.

So what can you do to minimize the safety risks of electronic medical records to you and those you care about? There are definitely some steps that I recommend.

First, always be prepared before going to a doctor’s visit. Bring a list of your medications with you, and jot down a reminder of anything that has changed medically since the last visit. Give it to the nurse who sees you before the doctor comes in, and ask him or her to make sure and update your record. It is also a good idea to give the same information to the doctor. You do not want your record to have inaccurate information.

Second, for hospitalizations, go in realizing that electronic medical records encourage “auto-pilot” behavior on the part of healthcare providers. I am saying that all of them are running on “auto-pilot,” but just that the temptation is there. Thus, I recommend that a patient should always have a loved one with him or her 24/7 during a hospitalization. And these companions should make sure and keep a journal of how the patient is doing and a general record of what care is being provided, including labs and radiology studies that are ordered and results.

And, finally, it is always appropriate for patients and their families to ask polite questions of doctors and nurses. Ask about results of tests that have been ordered. In a hospitalization, when the patient is acting strangely, ask for a doctor. And if you are not getting the answers or results you expect, ask more firmly or ask for attention from a different doctor. In this age of healthcare “point and clicking,” you do not want to fall through the cracks.

If you or someone you care for has been harmed by medical malpractice, call 281-580-8800, and the medical malpractice lawyers at Painter Law Firm will give you a free evaluation of your potential case.

Robert Painter

Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.

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